Hemodynamically self-corrected ΔADC analysis in idiopathic normal pressure hydrocephalus.

OBJECTIVE: To clarify the cause of higher water fluctuation of the brain in idiopathic normal pressure hydrocephalus (iNPH), we assessed change in hemodynamic-independent apparent diffusion coefficient during the cardiac cycle (ΔADC) in iNPH. METHODS: Electrocardiographically synchronized single-shot diffusion echo-planer imaging (b = 0, 500, and 1000 s/mm2) was performed in healthy volunteers, atrophic ventricular dilation group, and iNPH group, respectively. The ΔADC (b = 0 and 1000 s/mm2) and maximum ADC (b = 0 and 500 s/mm2) in the cardiac cycles were measured at the frontal white matter in the brain. Then, self-corrected ΔADC was obtained from the ΔADC divided by the maximum ADC (ADCpeak: perfusion-related diffusion) to correct the blood flow effect. RESULTS: The ΔADC after correction was significantly higher in the iNPH group than in the other two groups. However, there was no significant difference in ADCpeak values among the groups. CONCLUSION: Self-corrected ΔADC in iNPH increased because of changes in the biomechanical properties of the brain. Self-corrected ΔADC analysis makes it possible to obtain information on hemodynamically independent water fluctuation as well as perfusion in iNPH. ADVANCES IN KNOWLEDGE: Analysis self-corrected ΔADC provides simultaneously information on biomechanical properties, perfusion, and water fluctuation in iNPH.

Multiple Breath-hold Volumetric Modulated Arc Therapy Under Fluoroscopic Image Guidance with an Implanted Fiducial Marker: An Advanced Technique.

An advanced technique for multiple breath-hold volumetric modulated arc therapy (VMAT) has been proposed under fluoroscopic image guidance with a fiducial marker implanted close to a tumor. The marker coordinates on a digitally reconstructed radiography image at a gantry start angle, under a planned breath-hold condition, were transferred to the fluoroscopic image window. Then, a reference lateral line passing through the planned breath-hold marker position was drawn on the fluoroscopic image. Additional lateral lines were further added on both sides of the reference line with a distance of 3 mm as a tolerance limit for the breath-hold beam delivery. Subsequently, the patient was asked to breathe in slowly under fluoroscopy. Immediately after the marker position on the fluoroscopic image moved inside the tolerance range, the patient was asked to hold the breath and the VMAT beam was delivered. During the beam delivery, the breath-hold status was continuously monitored by checking if the deviation of the marker position exceeded the tolerance limit. As long as the marker stayed within the tolerance range, a segmented VMAT delivery continued for a preset period of 15 to 30 seconds depending on the breath-hold capability of each patient. As soon as each segmented delivery was completed, the beam interrupt button was pushed; subsequently, the patient was asked for free breathing. This procedure was repeated until all the segmented VMAT beams were delivered. A lung tumor case is reported here as an initial study. The proposed technique may be clinically advantageous for treating respiratory moving tumors including lung tumor, liver cancer, and other abdominal cancers.

A case of polypoid and papillary cystitis mimicking an advanced bladder carcinoma with invasion of perivesical fat.

A rare case of polypoid and papillary cystitis without a history of catheterization is reported. A 69-year-old man was admitted to our hospital because of pain during urination and gross hematuria. The cystscopic and imaging findings including ultrasound, CT, and MR image showed an irregular wall thickening and stranding in the perivesical fat, which indicated an advanced bladder carcinoma, but histopathological findings obtained by transurethral resection revealed polypoid and papillary cystitis. Such benign lesions need to be discussed in the differential diagnosis of patients with bladder tumor to avoid excessive resection.

[Descending necrotizing mediastinitis extended to empyema].

A 61-year-old man came to our hospital complained of neck swelling after extracting a tooth. Cervical drainage was performed in the diagnosis of cervical abscess. Two days later, left pleural effusion appeared and its bacteriologic culture showed Streptococcus constellatus. Computed tomography (CT) scan showed massive retained pus in the mediastinum. Thoracic drainage alone wasn't effective and the left thoracotomy was immediately performed to open the mediastinal pleura and curette the thoracic cavity. After surgery, left thoracic cavity was irrigated with a large volume of saline solution via the thoracic drains for a month, resulting in successful recovery. Immediate open drainage and irrigation are very important in case of descending necrotizing mediastinitis rapidly developing empyema.

Bronchial artery aneurysm embolization with NBCA.

We present a case of asymptomatic bronchial artery aneurysm that formed a fistula with part of the pulmonary artery (there was no definite fistula with the pulmonary vein). We were able to catheterize the feeding vessel but could not reach the aneurysm. We therefore injected a mixture of N-butyl-2-cyanoacrylate (NBCA; Histoacryl, B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) from the feeding vessel. The fistula, aneurysm, and feeding vessel were almost totally occluded. After embolization, the patient coughed a little; there were no other definite side effects or complications. One and 3 months later, on chest CT, the aneurysm was almost completely occupied with hyperattenuating NBCA-Lipiodol embolization. NBCA is a liquid embolization material whose time to coagulation after injection can be controlled by diluting it with Lipiodol. It is therefore possible to embolize an aneurysm, feeding vessels, and efferent vessels (in our case, it was a fistula) by using an NBCA-Lipiodol mixture of an appropriate concentration, regardless of whether the catheter can reach the aneurysm or not.

Primary hepatic carcinoid tumor with carcinoid syndrome and carcinoid heart disease: a case report of a patient on long-term follow-up.

We report a 57-year-old woman with a primary hepatic carcinoid tumor who had been suffering from symptoms due to carcinoid syndrome and carcinoid heart disease for more than 9 years. Long-term injection of octreotide acetate was fairly effective to relieve the symptoms due to carcinoid syndrome, but its tumor contraction effect was not confirmed. The massive ascites in the follow-up period appeared to be diminished to a certain extent by timely chemotherapy including cisplatin. The patient died of multi-organ failure about 9 years after the onset of disease. Autopsy confirmed a primary hepatic carcinoid tumor with limited distant metastases.